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Thursday, 25 July 2013

Maternal mortality: An English prince and a Lagos pauper

BY DEDE KADIRI

The birth of a boy, who is third in line to the English throne, has attracted global attention. Everyone likes a fairy tale and this birth seems to present a happy one. However, while we celebrate this distant prince, it is difficult to resist the opportunity to compare birthing conditions here in Nigeria and in the United Kingdom. An unfair comparism, no doubt, but this story has thrown up some interesting indicators that can be a pointer for possible growth in Nigeria’s health sector.

The newly-born English Prince George, comes with all the paraphernalia of wealth. Even the media attention regarding the birth method the mother chooses, has been massive. Some 6,718km from this celebrated event, Risikat gives birth to a bouncing baby boy in Lagos, Nigeria. But here, she struggles for survival. A story that is familiar to many families. Often, we talk about child birth experiences — costly hospital bills; the attitude of birth attendants and nurses to the women in labour; and women we know who nearly died or died in childbirth. In fact, at a recent conversation, I was surprised that issues of childbirth seemed to resonate well with men, who were willing to share horrifying stories of their wives’ experiences as well. An informal census of the incidence showed that in that small room, out of five women and men involved in a discussion, only one had not experienced complications in childbirth — and she gave birth abroad.

Nigeria has one of the worst maternal mortality indices in the world. With a ratio of 545 women who die out of 100,000 live births, the country has been ranked alongside Liberia, Sudan, Chad and Somalia. Effectively, this indicator translates to 75 women who die on a daily basis during childbirth in Nigeria – almost the equivalent to a plane crash of a Boeing 727 every couple of days.

The indicators are not much different in Lagos State, Nigeria’s commercial hub. In the state, 555 women die out of 100,000 live births. This means that out of every 40 women, one will die during gestation, childbirth or during six weeks after the end of pregnancy or delivery. This index is higher than the national average and with a population almost hitting 21 million, more women are likely to die in Lagos State than in other state in the country.

One way to understand the reason behind the alarming maternal deaths is to appreciate health care at the Primary Health Care facilities in the state. The PHCs are critical to women’s survival because they are located at the ward level in the local government areas and perceived to be closer to the people and therefore easily accessible. For many of Lagos State’s poor especially the over 10 million people who live below the poverty line and are unlikely to pay for expensive health care at private hospitals, the PHCs represent a viable option for childbirth.

However, a 2013 state-wide assessment of flagship PHCs in Lagos State conducted by InnovationMatters in partnership with the Lagos State Civil Society Partnership, found some interesting drivers of maternal mortality at this level. The assessment identified the non-availability of protocols, and supporting equipment to handlePost-Partum Hemorrhage, a leading cause of death resulting from excessive blood loss after birth, was largely absent. In other words, the study found that a good number of the PHCs assessed were not adequately equipped to handle such cases.

An instance can be taken from the availability of ambulances for women who suffer PPH. Even though 13 out of the 20 PHCs assessed have ambulances to handle emergencies or to transfer critical cases to the General Hospitals, seven of these ambulances are not fully functional having had challenges of maintenance and even imprest for fuelling the vehicle. In effect, out of the 20 PHCs assessed, only six have functional ambulances to handle emergencies. In one instance, a nurse at the Palm Avenue PHC, Mushin, stated that the ambulance was not available for 24 hours and that in some situations, “the patient is told to tell the husband to go with his car or use the taxi park close by.” In emergency cases like excessive bleeding, the chances of survival, can be slim.

This is not the only situation where cash-strapped patients are made to bear the cost of treatment. In the event of power outage, patients are made to contribute to the cost of fuelling a generator in eight out of 20 PHCs assessed. The assessment found that only six out of 20 PHCs have fully functional power supply back-up. For eight of the PHCs assessed, generators are not fully functional as a result of lack of imprest to purchase fuel to operate them. In some others, generators are not even available. A nurse in Ilasamaja remarked during the exercise, “… It is irregular! The last time we had light was two weeks ago and there is no imprest for fuel, so we make use of candle or torchlight even during delivery and since there is no light, no water; we fetch from the well.”

So, going back to our story, on July 22, 2013, the day the English Prince was born, Risikat died. She is survived by a husband and a bouncing baby boy.

This story is not an empty criticism of the health care system in Nigeria but is aimed at inspiring change and repurposing the true essence of local governance. Nigerians need to begin to ask questions. However, questions in connection with the appalling state of the PHCs and the increasing number of deaths must be directed to the correct channel – the local governments. This is because by virtue of the 1999 Constitution, the PHCs fall under the purview of the local governments. They have the responsibility to fund and equip the PHCs so that they meet the health needs of citizens within their jurisdictions.

Importantly, attention must be drawn to the fact that inadequate funding of ambulances and irregular power supply appear to be critical factors influencing poor quality of health care at the PHCs. Ultimately, poor funding can potentially lead to the deaths of many Nigerian women. Consequently, in addition to adequate budgetary provision by the LGAs, close budget monitoring is urgently needed at this level to check corruption and improve fiscal transparency. Without doubt, the commitment to reducing maternal mortality has to begin from the local government level and a process to ensure that LGA funds are prudently managed must be established if women’s survival is to be guaranteed in Lagos State.